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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 233009794
Report Date: 04/25/2024
Date Signed: 04/25/2024 04:47:45 PM


Document Has Been Signed on 04/25/2024 04:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:BOONT TRIBE COMMUNITY SCHOOL P/SFACILITY NUMBER:
233009794
ADMINISTRATOR:SEASHA ROBBFACILITY TYPE:
850
ADDRESS:8300 HIGHWAY 128TELEPHONE:
(707) 895-3590
CITY:PHILOSTATE: CAZIP CODE:
95466
CAPACITY:14CENSUS: 0DATE:
04/25/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:36 PM
MET WITH:Seasha RobbTIME COMPLETED:
04:59 PM
NARRATIVE
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A required annual inspection of the facility was conducted by Licensing Program Analyst (LPA) Robert Maciel, who met with Director Seasha Robb. The facility file was reviewed prior to this inspection. A review of the personnel report on file indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

The facility’s operating hours are 9:00 AM - 5:00 PM, Monday, Wednesday, and Friday. The facility was toured inside and outside and the floor and yard plan submitted by the licensee were verified. The sign-in/sign-out records were reviewed. Items which could pose a danger to children (such as detergents, cleaning compounds and medications) were observed to be inaccessible to children. Director stated poisons are not stored on site and none were observed by LPA. The toys, floors, desks and other equipment and surfaces are clean, toxic free, safe and in good condition. There is uncontaminated drinking water available to children indoors and outdoors by use of water jugs. The children's bathrooms are in safe and sanitary condition. Director stated that children provide food from home but if children are still hungry, the facility provides snack. Food prep areas are clean. Food is properly stored and refrigerated as needed. There was no contaminated food observed. Garbage cans containing solid waste have tight fitting lids. LPA observed a working carbon monoxide detector, smoke alarm, and fire extinguisher rated at least 2A10BC in the facility. Director stated that the facility has not completed a disaster drill within the past 6 months. Continued on LIC809-C
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert MacielTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BOONT TRIBE COMMUNITY SCHOOL P/S
FACILITY NUMBER: 233009794
VISIT DATE: 04/25/2024
NARRATIVE
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The playground equipment and surface areas are in safe condition. There is wood chip cushioning underneath climbing structures and/or play equipment to absorb falls. There were no bodies of water observed on the site. Director stated no weapons are stored on site, and none were observed. During today's inspection there were no preschool-age children at the facility. The facility was operating within the licensed capacity and ratio requirements. At least one staff member present during the inspection possessed current CPR and First Aid certifications, which expire in 4/20/26. Three staff records were reviewed at 3:48 PM and which revealed that staff 1 (S1) and staff 3 (S3) did not possess current mandated reporter training certificates, staff 1 (S1) did not possess proof of immunization against measles, staff 3 (S3) did not possess a compelte LIC503 Health Screening, and staff 1 - 3 (S1-S3) did not possess a complete Personnel Record. Five children’s records were reviewed at 2:57 PM which revealed that child 5 did not possess an immunization record. Director stated lead testing for faucets used for drinking and food preparation has not been completed.

LPA referred director to the Department website for lead: Lead Toxicity Prevention and Water Testing Information.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Continued on LIC 809C
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert MacielTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BOONT TRIBE COMMUNITY SCHOOL P/S
FACILITY NUMBER: 233009794
VISIT DATE: 04/25/2024
NARRATIVE
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To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

The following violations of the California Code of Regulation, Title 22, Division 12, were cited: see LIC809-D. Appeal Rights were provided. Exit interview conducted and report was reviewed with the Director Seasha Robb. A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert MacielTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 04/25/2024 04:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: BOONT TRIBE COMMUNITY SCHOOL P/S
FACILITY NUMBER: 233009794

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.16(a)(1)
Lead Testing
(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, director stated lead testing for faucets used for drinking and food preparation has not been completed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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Director stated that she would begin the lead testing process and send proof of progress to LPA by email at robert.maciel@dss.ca.gov.
Type B
Section Cited
CCR
101174(d)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the facility has not conducted a disaster drill within the last 6 months which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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Director stated she would conduct a drill and send a copy of the recorded log to LPA by emai lat robert.maciel@dss.ca.gov.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert MacielTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 04/25/2024 04:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: BOONT TRIBE COMMUNITY SCHOOL P/S
FACILITY NUMBER: 233009794

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on record review, staff 1 (S1) and staff 3 (S3) did not possess current Mandated Reporter Training Certificates which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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Director stated she would obtain current mandated reporter training certificates for S1 and S3 and send a copy to LPA by email at robert.maciel@dss.ca.gov.
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, staff 1 (S1) did not possess proof of immunization against measles which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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Director stated she would obtain proof of immunization against measles for S1 and send a copy to LPA by email at robert.maciel@dss.ca.gov.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert MacielTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
LIC809 (FAS) - (06/04)
Page: 5 of 7


Document Has Been Signed on 04/25/2024 04:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: BOONT TRIBE COMMUNITY SCHOOL P/S
FACILITY NUMBER: 233009794

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on record review, staff 3 (S3) did not possess a compelte LIC503 Health Screening which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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Director stated she would obtain staff 3's LIC501 Health Screening and send a copy to LPA by email at robert.maciel@dss.ca.gov.
Type B
Section Cited
CCR
101217(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on record review, staff 1 - 3 (S1-S3) did not possess a complete Personnel Record which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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Director stated she would obtain complete LIC501 Personnel Records for S1-S3 and send a copy to LPA by email at robert.maciel@dss.ca.gov.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert MacielTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
LIC809 (FAS) - (06/04)
Page: 6 of 7


Document Has Been Signed on 04/25/2024 04:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: BOONT TRIBE COMMUNITY SCHOOL P/S
FACILITY NUMBER: 233009794

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101220.1(g)
Immunizations
(g) The licensee shall document each child's immunizations and shall maintain such documentation in the center for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, child 5 (C5) did not possess an immunization record which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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2
3
4
Director stated she would obtain child 5's immunization record and send a copy to LPA by email at robert.maciel@dss.ca.gov.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert MacielTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
LIC809 (FAS) - (06/04)
Page: 7 of 7